What is the management approach for Intraventricular Hemorrhage (IVH)?

Management of Intraventricular Hemorrhage (IVH)

Immediate Life-Saving Intervention

Place an external ventricular drain (EVD) immediately in any patient with IVH causing hydrocephalus and decreased level of consciousness—this is a Class I, life-saving intervention that reduces mortality. 1, 2

Core Management Algorithm

Step 1: Assess Severity and Need for EVD

• Insert EVD emergently if: 1, 2

  • GCS ≤8 with hydrocephalus
  • Decreased consciousness attributable to hydrocephalus
  • Large IVH volume (Graeb score ≥7)
  • Blood occluding foramina of Monro or third ventricle (even without current hydrocephalus, as obstruction can develop precipitously) 3

• Use bolted and antibiotic-coated catheters rather than tunneled/uncoated catheters—this significantly reduces infection rates (P < 0.001) 2

Step 2: Add Intraventricular Fibrinolysis

Administer intraventricular alteplase (tPA) through the EVD for patients with GCS >3 and associated ICH volume <30 mL—this intervention reduces mortality from 40.9% to 22.4% and improves functional outcomes from 38.3% to 47.2%. 2

• Dosing protocol: 1 mg alteplase per 1 cm of maximum hematoma diameter, administered every 8-12 hours 2
• Contraindications: Unrepaired cerebral aneurysms, untreated arteriovenous malformations, and active coagulopathy 3
• Benefits beyond mortality: Reduces catheter occlusion from 37.3% to 10.6% (P = 0.0003) 2
• Complication rates: Symptomatic bleeding occurs in 4% and bacterial ventriculitis in 2% 2

Step 3: Correct Coagulopathy Before EVD Insertion

• Reverse warfarin completely 2
• Consider platelet transfusion if patient is on antiplatelet agents 2
• Check prothrombin time and partial thromboplastin time before catheter insertion 3

Step 4: ICP Monitoring and Management

• Monitor ICP, cerebral perfusion pressure, and hemodynamic function continuously 2

• First-line interventions for elevated ICP (>20 mm Hg): 2

  • Repeat CT scan to assess for hematoma expansion
  • Mannitol bolus 0.25-1.0 g/kg, OR
  • Hypertonic saline 23.4% 30 mL bolus
  • Drain CSF through the EVD

• Do NOT use corticosteroids for elevated ICP in ICH/IVH—they provide no benefit and should not be administered 1

Special Considerations for Aneurysmal IVH

When IVH is secondary to ruptured cerebral aneurysm, delay EVD insertion for non-life-threatening hydrocephalus until the aneurysm is surgically repaired, as lowering ICP increases transmural pressure across the aneurysm wall and precipitates rerupture. 3

However, if hydrocephalus is causing significant neurologic decline, insert EVD immediately despite unprotected aneurysm status, using extreme diligence to allow slow, controlled CSF release to mitigate rerupture risk. 3

Prognostic Context

IVH dramatically worsens outcomes—mortality increases from 20% in ICH without IVH to 51% in ICH with IVH. 2, 4 Approximately 30-50% of patients develop hydrocephalus requiring potential permanent shunting, though shunt dependency is unaffected by fibrinolysis use (P = 0.98). 2

Common Pitfalls to Avoid

• Do not wait for hydrocephalus to develop if blood is occluding ventricular pathways—insert EVD prophylactically as obstruction can occur precipitously and cause irreversible damage 3
• Do not use prophylactic hyperosmolar therapy—early prophylactic agents have not demonstrated efficacy in improving outcomes 1
• Do not routinely place ICP monitors in all ICH/IVH patients—the benefit is unclear except in those with GCS 9-12 where retrospective data suggests potential benefit 1
• Avoid rapid CSF drainage in aneurysmal IVH, as this increases rerupture risk 3

Alternative Approach: Neuroendoscopic Evacuation

Neuroendoscopic evacuation plus EVD (with or without thrombolytic) has uncertain effectiveness for improving functional outcomes and reducing permanent shunt dependence (Class IIb recommendation), and should only be considered in specialized centers. 2